Perinatal outcomes in singleton live births after fresh blastocyst-stage embryo transfer: a retrospective analysis of 67 147 IVF/ICSI cycles.

STUDY QUESTION: Are perinatal outcomes different between singleton live births conceived from fresh blastocyst transfer and those following the transfer of fresh cleavage-stage embryos? SUMMARY ANSWER: Fresh blastocyst transfer does not increase risks of preterm birth (PTB), low/high birth weight or congenital anomaly and does not alter the sex ratio at birth or prejudice the chance of having a healthy baby. WHAT IS KNOWN ALREADY: Extended embryo culture is currently considered the best option for embryo selection, but concerns have been raised about increased risks of preterm delivery and large-for-gestational-age (LGA) babies. STUDY DESIGN, SIZE, DURATION: We conducted a retrospective cohort study based on data from the Human Fertilisation and Embryology Authority (HFEA) anonymised and cycle-based dataset in the UK between 1999 and 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS: Baseline characteristics were compared between in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) blastocyst-stage and cleavage-stage embryo transfer cycles using the χ2 test for categorical/dichotomised covariates and the Mann-Whitney test for continuous covariates. Statistical significance was set at <0.005. Poisson regression and multinomial logistic regression were used to establish relationships between perinatal outcomes and blastocyst-stage embryo transfer or cleavage-stage embryo transfer. Risk ratios (RRs), adjusted risk ratios (aRRs) and their 99.5% confidence intervals (CIs) were calculated as a measure of strength of associations. Results were adjusted for clinically relevant covariates. A sub-group analysis included women undergoing their first IVF/ICSI treatment. The level of significance was set at <0.05, and 95% CIs were calculated in the sub-group analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Of a total of 67 147 IVF/ICSI cycles, 11 152 involved blastocyst-stage embryo(s) and 55 995 involved cleavage-stage embryo(s). The two groups were comparable with regards to the risk of PTB (aRR, 1.00; 99.5% CI, 0.79-1.25), very-preterm birth (VPTB) (aRR, 1.00; 99.5% CI, 0.63-1.54), very-low birth weight (VLBW) (aRR, 0.84; 99.5% CI, 0.53-1.34), low birth weight (LBW) (aRR, 0.92; 99.5% CI, 0.73-1.16), high birth weight (HBW) (aRR, 0.94; 99.5% CI, 0.75-1.18) and very-high birth weight (VHBW) (aRR, 1.05; 99.5% CI, 0.66-1.65). The risk of congenital anomaly was 16% higher in the blastocyst-stage group than in the cleavage-stage group, but this was not statistically significant (aRR, 1.16; 99.5% CI, 0.90-1.49). The chance of having a healthy baby (born at term, with a normal birth weight and no congenital anomalies) was not altered by extended culture (aRR, 1.00; 99.5% CI, 0.93-1.07). Extended culture was associated with a marginal increase in the chance having a male baby in the main cycle-based analysis (aRR, 1.04; 99.5% CI, 1.01-1.09) but not in the sub-group analysis of women undergoing their first cycle of treatment (aRR, 1.04; 95% CI, 1.00-1.08). In the sub-group analysis, the risk of congenital anomalies was significantly higher after blastocyst-stage embryo transfer (aRR, 1.42; 95% CI, 1.12-1.81). LIMITATIONS, REASONS FOR CAUTION: This study is limited by the use of observational data and inability to adjust for key confounders, such as maternal smoking status and body mass index (BMI), which were not recorded in the HFEA dataset. As the main analysis was cycle-based and we were unable to link cycles within women undergoing more than one IVF/ICSI cycle, we undertook a sub-group analysis on women undergoing their first treatment cycle. WIDER IMPLICATIONS OF THE FINDINGS: Our findings should reassure women undergoing blastocyst-stage embryo transfer. For the first time, we have shown that babies born after blastocyst transfer have a similar chance of being healthy as those born after cleavage-stage embryos transfer. STUDY FUNDING/COMPETING INTEREST(S): The research activity of Dr Nicola Marconi was funded by the scholarship 'A. Griffini-J. Miglierina', Fondazione Comunitaria del Varesotto, Provincia di Varese, Italy. The authors do not have any competing interests to disclose. TRIAL REGISTRATION NUMBER: N/A.

Impact of Sport Activity and Physical Exercise on Obstetrical and Perineal Outcomes at Delivery: A Prospective Study.

OBJECTIVE: This study was aimed to investigate the effects of physical activity on perineal outcomes at delivery according to the different levels and types of maternal physical activity before and during pregnancy. STUDY DESIGN: We prospectively evaluated the obstetrical and perineal outcomes of all consecutive women who delivered at the Del Ponte Hospital, in the period between July 2014 and September 2014. Women were divided into three groups according to the features of physical activity performed before pregnancy: group 1: "very sporty women," group 2: "moderately sporty women," and group 3: "inactive women." A subanalysis of our data was performed based on the specific type of sport activity, on the degree of involvement of perineal muscles during physical activity, and on the continuation/discontinuation of this activity during pregnancy. RESULTS: A total of 135, 84, and 85 women were included in group 1, group 2, and group 3, respectively. The demographic characteristics were comparable among all the groups. Sport activity during pregnancy was more frequent in groups 1 and 2 (59.3 and 53.6%, respectively, vs. 29.4% in group 3; p = 0.003). No differences among groups were detected in terms of perineal outcomes. A lower rate of episiotomy/lacerations ≥ 2nd degree was found among women who practiced sports that specifically involved the perineal muscles and who continued this practice during pregnancy. CONCLUSION: Perineal outcomes are not influenced by the intensity of sport activity performed before/during pregnancy. Continuous sports during pregnancy that specifically train the perineal muscles are associated with a lower rate of episiotomy and perineal lacerations ≥ 2nd degree.

Pregnancy after Endometriosis: Maternal and Neonatal Outcomes according to the Location of the Disease.

OBJECTIVE: To systematically evaluate pregnancy and labor course, obstetrical complications, and maternal and neonatal outcomes in women with endometriosis, stratifying according to the specific location of the disease. STUDY DESIGN: We retrospectively analyzed our prospectively maintained obstetrical database from January 2011 to August 2014 to identify all women with a previous histological diagnosis of endometriosis who delivered at our institution (cases). We divided the cases according to the specific location of the disease (deep infiltrating endometriosis, ovarian endometriosis, and peritoneal endometriosis). As controls, we identified all unaffected women who delivered in the year 2013. To avoid the confounding effect of parity, we limited our analysis to nulliparous women. RESULTS: A total of 118 nulliparous women with endometriosis and 1,690 nulliparous controls were identified. Women with endometriosis were significantly older, had a lower body mass index, and had a higher incidence of assisted reproductive technology. The duration of pregnancy was significantly shorter among women with endometriosis. A higher incidence of placenta previa (3.4 vs. 0.5%; p = 0.006), hypertension (11 vs. 5.9%; p = 0.04), cesarean section (41.5 vs. 24.2%; p < 0.0001), and vacuum delivery (10.1 vs. 2.9%; p = 0.006) was found in women with endometriosis. Neonatal outcomes were similar between groups. The incidence of placenta previa in patients with deep endometriosis was 11.7 versus 0.5% among controls (p < 0.0001), whereas in women with ovarian and peritoneal endometriosis, it was similar to the controls. CONCLUSION: Women with endometriosis have a higher incidence of vacuum delivery, cesarean section, and placenta previa compared with unaffected women. The higher risk of placenta previa is attributable exclusively to women with deep endometriosis. Neonatal outcomes are unaffected by the presence of the disease.

Laparoscopic Versus Open Hysterectomy for Benign Disease in Uteri Weighing >1 kg: A Retrospective Analysis on 258 Patients.

STUDY OBJECTIVE: To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications. DESIGN: A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2). SETTING: An academic research center. PATIENTS: Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished. INTERVENTIONS: Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy). MEASUREMENTS AND MAIN RESULTS: Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p < .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients. CONCLUSION: In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.

Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires.

PURPOSE: Radical eradication of deep infiltrating endometriosis (DIE) is associated with a high risk of iatrogenic autonomic denervation and pelvic dysfunction. Our aim was to prospectively analyze peri-operative details and post-operative functional outcomes (in terms of pain relief and bladder, rectal, and sexual function) among women operated for DIE of the posterior compartment with nerve-sparing technique, using the visual analogue scale and validated questionnaires. METHODS: All women undergoing laparoscopic nerve-sparing eradicative surgery for DIE nodules of the posterior compartment ≥ 4 cm ± bowel resection were included. Pain scores [using Visual Analogue Scale (VAS) scores] were collected before surgery and 6 and 12 months after surgery. Functional outcomes in terms of bladder, rectal, and sexual function, were evaluated using validated questionnaires (i.e., ICIQ-UISF, NBD score, and FSFI) administered pre-operatively and 6 months after surgery. MAIN RESULTS: A total of 34 patients were included. Twenty-eight (82.4%) of them had already undergone a previous abdominal surgery for endometriosis. Bowel resection was performed in 16 (47.1%) patients. Median VAS score levels of pelvic pain were significantly decreased after surgery both at 6 (median 3, range 0-7 and 2, 0-7, respectively) and at 12 months (3, 0-8 and 2, 0-7), compared to pre-operative levels (9, 1-10 and 3, 0-7, respectively) (p < 0.0001). No differences were found in terms of urinary function between pre- and post-operative ICIQ-SF questionnaires. In no cases, bladder self-catheterization was needed at the 6-and 12-month follow-up. Median NBD score was 3.5 (0-21) pre-operatively and 2 (0-18) after 6 months (p = 0.72). The pre-operative total FSFI score was 19.1 (1.2-28.9) vs. 22.7 (12.2-31) post-operatively (p = 0.004). CONCLUSIONS: The nerve-sparing approach is effective in eradicating DIE of the posterior compartment, with satisfactory pain control, significant improvement of sexual function, and preservation of bladder and rectal function.

Laparoscopic Versus Open Hysterectomy for Benign Disease in Women with Giant Uteri (≥1500 g): Feasibility and Outcomes.

UNLABELLED: STUDY OBJECTIVE: To evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference. DESIGN: A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2). SETTING: An academic research center. PATIENTS: All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH. INTERVENTIONS: Hysterectomy ± mono/bilateral salpingo-oophorectomy. MAIN OUTCOME MEASURES: Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes. RESULTS: AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p < .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years. CONCLUSIONS: Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay.

Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy.

PURPOSE: Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis. METHODS: Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease. RESULTS: One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal-mild, and 83 (74.1 %) with moderate-severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs. CONTROLS: Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien-Dindo classification system was higher in the endometriosis group (Clavien-Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate-severe endometriosis vs. CONTROLS: No differences between patients with minimal-mild endometriosis and controls were found. CONCLUSION(S): TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis.

Fertility rates, course of pregnancy and perinatal outcomes after laparoscopic ureterolysis for deep endometriosis: A long-term follow-up study.

We evaluated fertility rates, pregnancy course and maternal/neonatal outcomes following laparoscopic ureterolysis for deep endometriosis. Data about women who underwent laparoscopic excision of ureteral endometriosis were analysed. After exclusion of women who underwent hysterectomy/bilateral adnexectomy at initial surgery, and those lost-to-follow-up or with follow-up <1 year, a total of 61 patients were included. Of them, 36 (59%) wished to conceive after surgery. Twenty women became pregnant: nine (45%) of them after assisted reproductive technologies. Twenty-six pregnancies were observed with four (15.6%) miscarriages. Median gestational week at delivery was 38 weeks + 2 days (range, 33 + 1-41 + 6), with three (13.6%) and two (9%) deliveries before 37 and 34 weeks, respectively. Nine caesarean sections were performed (40.9%). Fertility rates after laparoscopic ureterolysis are comparable to those of other women operated for other forms of deep endometriosis. Apart from a higher risk of caesarean and preterm birth, the course of pregnancy and peripartum outcomes appear encouraging.

Perinatal outcomes in singleton live births after blastocyst transfer: an analysis of 60,926 in vitro fertilization cycles from the United Kingdom.

OBJECTIVE: To compare perinatal outcomes between singleton live births after blastocyst-stage and cleavage-stage fresh embryo transfer using data from all United Kingdom licensed fertility clinics. DESIGN: A cohort study. SETTING: Not applicable. PATIENT(S): A total of 60,926 in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles resulting in a singleton live birth after blastocyst-stage and cleavage-stage fresh embryo transfer between 2012 and 2018. INTERVENTION(S): Baseline characteristics between IVF/ICSI blastocyst and cleavage-stage transfer groups were compared using the χ2 test for categorical/dichotomized variables and the Mann-Whitney test for continuous variables. Statistical significance was set at <.05. Association between perinatal outcomes and blastocyst transfer compared with cleavage-stage transfer was assessed using multinomial logistic regression, adjusting for confounders selected using directed acyclic graphs (95% confidence interval [CI], adjusted relative risk ratio [aRRR]). A subgroup analysis included cycles in women undergoing their first IVF/ICSI cycle. MAIN OUTCOMES MEASURE(S): Gestational age at birth and birth weight. RESULT(S): The blastocyst group comprised 42,677 IVF/ICSI cycles and cleavage-stage group 18,249 cycles. There was likely little to no difference in the risk of preterm (aRRR, 1.07; 95% CI, 1.00-1.15) and very preterm birth (aRRR, 1.05; 95% CI, 0.91-1.21) in singleton live births after fresh blastocyst and cleavage-stage transfer. Risks of low birth weight (aRRR, 1.02; 95% CI, 0.95-1.09), very low birth weight (aRRR 0.96; 95% CI, 0.83-1.11), high birth weight (aRRR, 0.97; 95% CI, 0.90-1.04), and very high birth weight (aRRR, 0.91; 95% CI, 0.77-1.08) were likely similar between the groups. The findings were consistent in the subgroup analysis. CONCLUSION(S): Fresh blastocyst transfer does not appear to have a negative impact on gestational age at birth and birth weight in singleton live births compared with fresh cleavage-stage transfer.

Obstetric and perinatal outcomes of singleton pregnancies after blastocyst-stage embryo transfer compared with those after cleavage-stage embryo transfer: a systematic review and cumulative meta-analysis.

BACKGROUND: Extended embryo culture to blastocyst stage is widely used in IVF and is the default strategy in most clinics. The last decade has witnessed a growing interest in obstetric-perinatal outcomes following blastocyst transfer. Recent studies have challenged the conclusions of systematic reviews that associate risks of preterm birth (PTB) and large for gestational age (LGA) babies with blastocyst transfer. A higher proportion of blastocysts is transferred as frozen-thawed embryos, which may also have added implications. OBJECTIVE AND RATIONALE: The aim of this study was to conduct an updated systematic review of the obstetric-perinatal outcomes in singleton pregnancies following blastocyst-stage transfer compared to cleavage-stage transfer in IVF/ICSI cycles. Where deemed appropriate, data were combined in cumulative meta-analyses. SEARCH METHODS: Data sources from Medline, EMBASE, CINAHL, Web of Science, the Cochrane Central Register of Clinical Trials and the International Clinical Trials Registry Platform (ICTRP) (1980-2020) were searched using combinations of relevant keywords. Searches had no language restrictions and were limited to human studies. Observational studies and randomized controlled trials comparing obstetric-perinatal outcomes between singleton pregnancies after blastocyst-stage transfer and those after cleavage-stage transfer in IVF/ICSI cycles were sought. Two independent reviewers extracted data in 2 × 2 tables and assessed the methodological quality of the relevant studies using the Critical Appraisal Skills Programme scoring. Cumulative meta-analyses were carried out with independent analysis of pregnancies after fresh and frozen embryo transfers, using the Comprehensive Meta-Analysis software. If provided by included studies, adjusted effect sizes were combined in a sensitivity analysis. OUTCOMES: A total of 35 studies were included (n = 520 769 singleton pregnancies). Outcome data suggest singleton pregnancies following fresh blastocyst transfer were associated with higher risk of LGA (risk ratio (RR) 1.14; 95% CI 1.05-1.24) and very PTB (RR 1.17; 95% CI 1.08-1.26) compared to fresh cleavage-stage transfer. Singleton pregnancies following frozen blastocyst transfer were associated with higher risks of LGA (RR 1.17; 95% CI 1.08-1.27), PTB (RR 1.13; 95% CI 1.03-1.24) and caesarean section (RR 1.08; 95% CI 1.03-1.13) but lower risks of small for gestational age (RR 0.84, 95% CI 0.74-0.95) and perinatal mortality (RR 0.70; 95% CI 0.58-0.86). Increased risks of LGA and PTB after frozen blastocyst transfer persisted in the sensitivity analysis, which also showed a significantly increased risk of PTB after fresh blastocyst transfer. Cumulative meta-analyses revealed consistency in prevalence and magnitude of risks for a number of years. Data on other perinatal outcomes are still evolving. WIDER IMPLICATIONS: While the available evidence is predominantly reassuring in the context of blastocyst-stage embryo transfer, observational data suggest that blastocyst transfer is associated with a higher risk of LGA. This holds true irrespective of fresh or frozen transfer. Meta-analysis of adjusted data showed an increased risk of PTB with fresh and frozen blastocyst transfer. However, the quality of available evidence ranges from low to very low. Although blastocyst-stage embryo transfer remains the default position in most centres, based on individual risk profile we may need to consider cleavage-stage embryo transfer in some to mitigate the risk of LGA/PTB.

Outcomes of pregnancies using donor sperm compared with those using partner sperm: systematic review and meta-analysis.

BACKGROUND: Registry data from the Human Fertilisation and Embryology Authority (HFEA) show an increase of 40% in IUI and 377% in IVF cases using donor sperm between 2006 and 2016. OBJECTIVE AND RATIONALE: The objective of this study was to establish whether pregnancies conceived using donor sperm are at higher risk of obstetric and perinatal complications than those conceived with partner sperm. As more treatments are being carried out using donor sperm, attention is being given to obstetric and perinatal outcomes, as events in utero and at delivery have implications for long-term health. There is a need to know if there is any difference in the outcomes of pregnancies between those conceived using donor versus partner sperm in order to adequately inform and counsel couples. SEARCH METHODS: We performed a systematic review and meta-analysis of the outcomes of pregnancies conceived using donor sperm compared with partner sperm. Searches were performed in the OVID MEDLINE, OVID Embase, CENTRAL and CINAHL databases, including all studies published before 11 February 2019. The search strategy involved search terms for pregnancy, infant, donor sperm, heterologous artificial insemination, donor gametes, pregnancy outcomes and perinatal outcomes. Studies were included if they assessed pregnancies conceived by any method using, or infants born from, donor sperm compared with partner sperm and described early pregnancy, obstetric or perinatal outcomes. The Downs and Black tool was used for quality and bias assessment of studies. OUTCOMES: Of 3391 studies identified from the search, 37 studies were included in the review and 36 were included in the meta-analysis. For pregnancies conceived with donor sperm, versus partner sperm, there was an increase in the relative risk (RR) (95% CI) of combined hypertensive disorders of pregnancy: 1.44 (1.17-1.78), pre-eclampsia: 1.49 (1.05-2.09) and small for gestational age (SGA): 1.42 (1.17-1.79) but a reduced risk of ectopic pregnancy: 0.69 (0.48-0.98). There was no difference in the overall RR (95% CI) of miscarriage: 0.94 (0.80-1.11), gestational diabetes: 1.49 (0.62-3.59), pregnancy-induced hypertension (PIH): 1.24 (0.87-1.76), placental abruption: 0.65 (0.04-10.37), placenta praevia: 1.19 (0.64-2.21), preterm birth: 0.98 (0.88-1.08), low birth weight: 0.97 (0.82-1.15), high birthweight: 1.28 (0.94-1.73): large for gestational age (LGA): 1.01 (0.84-1.22), stillbirth: 1.23 (0.97-1.57), neonatal death: 0.79 (0.36-1.73) and congenital anomaly: 1.15 (0.86-1.53). WIDER IMPLICATIONS: The majority of our findings are reassuring, except for the mild increased risk of hypertensive disorders of pregnancy and SGA in pregnancies resulting from donor sperm. However, the evidence for this is limited and should be interpreted with caution because the evidence was based on observational studies which varied in their quality and risk of bias. Further high-quality population-based studies reporting obstetric outcomes in detail are required to confirm these findings.

Risk of peripartum hysterectomy in births after assisted reproductive technology.

OBJECTIVE: To investigate whether women who conceive after assisted reproductive technology (ART) are at higher risk for emergency peripartum hysterectomy. DESIGN: A case-control study using a prospectively maintained institutional database. SETTING: A tertiary referral university teaching maternity hospital. PATIENT(S): Thirty-one women who underwent peripartum hysterectomy for management of hemorrhage, and 19,902 control women. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Association between potential predictors and peripartum hysterectomy. RESULT(S): The incidence of peripartum hysterectomy was 1.7 cases per 1,000 births (95% confidence interval [CI] 1.2-2.4). After adjustment for maternal age and twin pregnancy, placenta previa (odds ratio [OR] 50.78, 95% CI 23.30-110.68), prior cesarean delivery (OR 6.72, 95% CI 2.99-15.09 for one cesarean; OR 6.80, 95% CI 1.45-31.90 for two or more cesareans), previous myomectomy (OR 24.59, 95% CI 6.70-90.19), and ART conception (OR 5.98, 95% CI 2.18-16.40) were all antenatal predictors for peripartum hysterectomy. In women having a peripartum hysterectomy, 13.4% of the risk is attributable to mode of conception. CONCLUSION(S): A history of ART increases the likelihood of needing a peripartum hysterectomy to control hemorrhage. Further investigation is needed to determine whether ART conception should be included in algorithms of risk stratification for emergency cesarean hysterectomy and plan of care be modified accordingly.

Hysterectomy in patients with previous cesarean section: comparison between laparoscopic and vaginal approaches.

OBJECTIVE: To evaluate surgery-related outcomes of laparoscopic (LH) and vaginal hysterectomy (VH) in patients with a history of previous cesarean section (CS). STUDY DESIGN: Data on 289 consecutive patients with a history of CS undergoing VH (n = 49, 17%) and LH (n = 219, 76%) were collected. Basic descriptive statistics, univariate and multivariate analyses were performed to evaluate surgery-related outcomes. A propensity-matched algorithm was applied in order to reduce allocation biases between groups. RESULTS: Patients undergoing LH were more likely to have a history of multiple cesarean sections (44% vs. 18%; p = 0.001). Additionally, uterine weight was greater among patients undergoing LH than VH (median weight: 235 (range, 45-2830) vs. 150 (range, 40-710)g; p < 0.001). Three patients in each group experienced procedural bladder injuries (3/219 (1%) vs. 3/49 (6%); p = 0.07; RR: 1.65; 95%CI: 0.74, 3.68). The rate of grade 3 or worse postoperative complications was balanced between LH and VH (1% vs. 0%; p = 1.00). Patients undergoing LH experienced a shorter length of hospital stay in comparison to patients undergoing VH (1 vs. 2 days; p = 0.02). Considering the overall population, we observed via multivariate analysis that age (OR: 1.003 (95%CI: 1.001, 1.004) per 10-year increase in age; p = 0.002), VH (OR: 17.80 (95%CI: 1.762, 180,378); p = 0.01) and number of cesarean sections ≥ 2 (OR: 27.70 (95%CI: 1.976, 388,285); p = 0.01) increased the risk of developing bladder injuries during hysterectomy. CONCLUSIONS: LH is a safe and feasible procedure in patients with previous CS, and it is associated with a low bladder injury rate.

Laparoscopic and vaginal approaches to hysterectomy in the obese.

OBJECTIVE: The aim of the study was to compare surgery-related outcomes between laparoscopic (LH) and vaginal (VH) hysterectomy, performed for benign uterine disease (other than pelvic organs prolapse) in obese women. STUDY DESIGN: Data of consecutive obese (BMI≥30) patients undergoing LH and VH, between 2000 and 2013, were compared using a propensity-matched analysis. One hundred propensity-matched patient pairs (200 patients) undergoing LH (n=100) and VH (n=100) represented the study group. RESULTS: Baseline demographic characteristics were similar between groups. Patients undergoing LH experienced similar operative time (87.5 (25-360) vs. 85 (25-240)min; p=0.28), slightly lower blood loss (100 (10-3200) vs. 150 (10-800)ml; p=0.006) and shorter length of hospital stay (1 (1-5) vs. 2 (1-5) days; p<0.001) than women undergoing VH. There was no statistically significant difference between LH and VH in complication rate (3% for VH vs. 10% for LH; OR: 3.4; 95%CI: 0.95-13.5; p=0.08). At multivariable analysis complication rates increased as BMI increase (OR: 1.01 (1.00-1.02) for 1-unit increase in BMI; p=0.05). Independently, LH correlated with reduced hospital stay (OR: 0.63 (95%CI: 0.49-0.82); p=0.001) and complication rates (OR: 0.91 (95%CI: 0.85-0.97); p=0.01). CONCLUSIONS: In obese women affected by benign uterine disease LH and VH should not be denied on the basis of the mere BMI, per se. In this setting, LH upholds effectiveness of VH, improving postoperative outcomes. However, complication rate increases as BMI increase, regardless surgical route.

A prospective case-control study on the impact of neoadjuvant chemotherapy on surgery-related outcomes of laparoscopic radical hysterectomy.

AIM: To investigate whether perioperative outcomes of class III/type C laparoscopic radical hysterectomy (LRH) for cervical cancer (CC) are influenced by neoadjuvant chemotherapy (NACT). PATIENTS AND METHODS: Data of consecutive patients, affected by locally advanced-stage CC, undergoing NACT plus LRH were matched 1:2 with consecutive patients, affected by early-stage CC who underwent LRH without NACT. RESULTS: Twenty and 40 patients underwent NACT with LRH and LRH aIone, respectively. Demographic characteristics were balanced between groups. Number of lymph nodes yielded, parametrial width and length of vaginal cuff were not influenced by preoperative administration of NACT. Patients undergoing NACT plus LRH experienced slightly higher blood loss (225 vs. 200 ml; p=0.05) than patients in the control group, but had a similar operative time and length of hospital stay. No between-group differences in transfusion and complications rates were observed (p>0.2). CONCLUSION: The administration of NACT does not affect the surgery-related outcomes of LRH.